2663.6 Final Determination By SSA

A final disability determination by Social Security occurs when SSA approves benefits or determines the individual does not meet disability criteria, and no further administrative appeal rights remain. If the individual does not request a timely appeal (per the SSA allowed timeframes), the SSA determination is final. A timely appeal places the SSA determination in pending status and is not considered final.

Coverage under PMD must be monitored for a final SSA disability determination. Coverage ends when SSA makes a final determination.

Favorable SSA Decision - A favorable SSA decision is a finding of disability and may, but does not always, result in benefit payment. A favorable decision is treated as a reported change and processed in accordance with the change processing rules of the applicable medical assistance program. The PMD eligibility segment must be closed and a final eligibility determination made under the appropriate Medicaid coverage group. For example: For Medically Needy, the change is processed the month following the month of change. For Working Healthy, the change is processed the following month, but will not impact the monthly premium amount until the 6-month desk review or regular review. If the individual becomes eligible under another Medicaid program, eligibility must be established under that group. Ongoing eligibility remains subject to continuing disability reviews as described in 2662.7 . PMD-eligible months do not need to be overlaid with non-PMD Medicaid eligibility. However, eligibility must be reviewed for prior months when: The individual’s protected filing date with Medicaid is prior to the effective date of PMD eligibility. If a disability onset date is established prior to the date of PMD eligibility, coverage must be determined for the applicable months. The individual receives Tier 2/MediKan coverage. Coverage under Medicaid must be determined for MediKan eligible months.

Unfavorable SSA Decision - If SSA determines the individual does not meet disability criteria, eligibility under PMD ends. Coverage provided during the presumptive period is not overstated when eligibility was otherwise correctly determined.

If the individual timely appeals the SSA decision and SSA accepts the appeal, the determination is not final and eligibility may continue if all other eligibility requirements are met.

NOTE : When SSA will not make a disability determination and a referral is made to Disability Determination Services (DDS) as described in 2662.2(3) , the DDS decision is considered the final disability determination for purposes of this section. A subsequent SSA application does not establish a protected filing date for the original medical assistance application associated with the DDS decision. See also the note in 2662.10 .